Provider Demographics
NPI:1467405423
Name:LOPEZ DE VICTORIA, MILLIED (DMD)
Entity Type:Individual
Prefix:
First Name:MILLIED
Middle Name:
Last Name:LOPEZ DE VICTORIA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 SW 216TH ST
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1003
Mailing Address - Country:US
Mailing Address - Phone:305-253-5100
Mailing Address - Fax:
Practice Address - Street 1:18255 HOMESTEAD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-5564
Practice Address - Country:US
Practice Address - Phone:305-278-6420
Practice Address - Fax:786-573-2867
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN178151223G0001X
NC76921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076638100Medicaid
NC89902U9Medicaid
NC89902U9Medicaid